HN: What have we learned about concussions that maybe we didn’t know a decade or two or three ago?

CT: There are about 30 things that we didn’t know just 10 years ago. For example, the adolescent brain seems to be most susceptible to concussion and takes the longest to recover. It’s rather unfortunate because that age is when kids are now big enough and fast enough that they are getting concussions—it’s also the risk-taking age.

Also, women appear to concuss more easily than men; and that holds for sports like hockey and basketball. We’re not really sure why that is but that’s what the data is telling us.

Unfortunately, there are still a lot of unanswered questions about concussions. We still don’t know the exact mechanism—although, rotational acceleration is more important in producing concussions than linear acceleration. And also, we don’t know how to detect a concussion on imaging techniques; for example, there is no telltale sign on a CAT Scan. And the MRI (magnetic resonance imaging) is still not showing us the effects of concussion. We are hopeful that some newer sequences of MRI will be more informative.

A concussion is still a clinical diagnosis, meaning that it depends on a knowledgeable examiner, like a physician, as well as a compliant patient. And not all patients are compliant; there are still people who want to hide the symptoms and signs of a concussion.

HN: How important is recognition of a concussion?

CT: All you have to do is look at Sidney Crosby—the fact that he got his first concussion on a Monday and it wasn’t recognized; and then on the Wednesday, he got his second concussion and it took a year to recover. It’s important to sit out until you’ve fully recovered and follow the six-step process of gradually incorporating more physical activity, so that your brain is ready to take another hit. If you run around the block and get a headache and get dizzy, that means your brain is not ready for the next hit and then you’re subject to the serious consequences of another concussion because your brain has not recovered fully from the first one.

I am a sports nut, that should go without saying, but one of the most exciting sports has begun its campaign. Living in Illinois, I am often reminded of who are the current keepers of Lord Stanley’s Cup but I also have a keen eye on my hometown team, the Colorado Avalanche. With all that being said I do not follow hockey nearly as well as football, or my own high school sports (our soccer team in undefeated). However, this is a sport that is also classified as a collision sport and is predisposed to disproportionate amounts of head trauma.

This season there should be some interesting findings about concussions as a confluence of a few rule changes as well as an Olympic schedule may in fact reduce the incidence of concussion, here is why;

Longer season (not strike shortened) so the players don’t feel the pressure to play so damned hard so quickly

Olympic schedule will have players worried about country over NHL when the winter gets in full swing

Fighters must keep helmets on for fights (I guess visored players cannot fight) for protection when falling to the ice

Rule 48 is in its third year, referees, players and the league have a better grasp on the outlawed hits

The NFL season starts on September 5 and you can be sure that soon all of the talk about brain injuries will focus on football; how do we make the game safer for the athletes, but still keep it the game that fans love (and will pay to watch)? Then there’ll be talk about the culture of the game and how it’s taught and coached at the youth level. Those questions, and other iterations of those themes, will be explored in the U.S. – definitely watch FRONTLINE: “League of Denial” – and maybe a bit in Canada, but the discussion won’t really get going in Canada until the NHL starts again. So from September to April (maybe June), national/international focus on brain injury is sifted through the major sports screen. In those 8-10 months, it’s sports, and virtually sports alone, that drive the discussion on brain injury. Don’t get me wrong, it’s great that people are talking about it, but if brain injury seems to only happen to pro athletes with the very best in medical services to help them recover and the most pressing issue is how soon they can get back on the field or ice , then instead of increasing awareness of a serious injury, these discussions lessen the seriousness and the effect of these injuries to most people who are not privy to those medical services and who will likely need more than a few days or weeks to recover.

I know we all think of late August and early September as football season, but there are other sports out there that deserve some attention as well. I do empathize with the football coaches that constantly tell me we are “picking” on that particular sport – we are not. It is tough to overlook a sport that garners the most eyes and advertising around here. That being said there are other sports either just starting, gearing up or in the final stretch that deserve note.

Baseball is grinding to the playoff push and under the radar is the fact that catchers are finally being honest about their heads. Many have hit the DL this year for concussions, most recently Joe Mauer of the Minnesota Twins. Certainly there have been others but it is worth noting that late in the season, seeing catchers develop concussions should not, nor will it be a surprise in the future.

Summer heat does not make one immediately think of ice rinks and hockey pucks, but Canada’s most popular sport will soon be getting into camp to prepare for the upcoming season. When the puck does finally drop in early October (Go Avs!) the NHL looks to improve on their better handle on concussions. But, the bigger reason for preparing for the hockey season is the upcoming Ice Hockey Summit II, held at the Mayo Clinic; Continue reading →

The Mayo Clinic is hosting their second Ice Hockey summit, October 8th and 9th in Rochester, Minnesota. The title on this one is “Action on Concussions”;

The prevalence and consequences of concussion at all levels of ice hockey are concerning. Reduction of concussion risk, as well as improved concussion diagnosis and management require a collaborative effort from medicine, psychology, sport science, coaching, engineering, officiating, manufacturing, and community partners. This quality scientific program focuses on education and generates an evidence-based action plan designed to make a difference.

Registration fee is $275-350 and space is limited so make your plans now, and click above. Continue reading →

While I didn’t intend to write a post about brain injury in sport, I was inspired to write it based on some events in the NHL playoffs. Since it’s not my point to dissect the danger of the two hits, I won’t spend much time on them. In fact, I’ll just share the links to the Gryba hit on Eller and the Abdelkader hit on Lydman. Seriously, whether I think either of those hits was clean or delivered with malicious intent is not, in any way, the basis or inspiration for this post. What is, is the idea that we – the North American contact sports-loving public – have all but abdicated our right to a free conscience. Whether either hitter was deserving of the suspension they have subsequently received, depends not on the hit they delivered, but on which team you cheer for (or against), or whether or not you like seeing big hits in hockey. It has nothing to do with what happened.

Some people don’t like where the NHL or NFL are heading; the frequency with which penalties are called when a player hits anywhere near an opposing player’s head. I don’t think that either of these two leagues, NHL and NFL, understand the concept of risk and reward. Hard hitting contact sports are so popular because they exhibit risk in a raw form. That’s probably why some/many of the athletes who make it to the highest levels get into the types of trouble they do. We watch news about multi-millionaire athletes who crash Porsches or who get arrested, and we may think “why would someone with so much to lose risk so much?” However, the athletes actually made logical (that doesn’t necessarily mean good) decisions. They do what all of us do before making most decisions. They, however briefly, look at their risk/reward histories plus their confidence Continue reading →

“I have a theory on concussions,” he said. “I think the reason there’s so much more of them — obviously the impact and the size of the equipment and the size of the player — but there’s another factor: everyone wears helmets, and under your skull when you have a helmet on, there’s a heat issue.

“Everyone sweats a lot more, the brain swells. The brain is closer to the skull. Think about it. Does it make sense? Common sense?” said Carlyle, who said he’d never talked to a doctor about his premise, which he was introduced to by Jim Pappin, the former Leaf who also played his career helmet free.

“I don’t know if it’s true, but that would be my theory. Heat expands and cold contracts. The brain is like a muscle, it’s pumping, it swells, it’s a lot closer to the outside of the skull.”

It is a common thought that crosses my mind when I see questionable actions around a concussion situation. Unfortunately I don’t have the power to get the answers, so I basically post them on here for others to see.

This is not the case in Australian Rules Football; if you are team and you receive a “please explain” regarding an injury (mainly concussions) you are probably treading on thin ice.

Interim Kangaroos chief executive Cameron Vale emailed AFL operations manager Adrian Anderson on Monday after the Roos were told to respond to a ”please explain” issued by the league last week.

The Kangaroos have been under investigation over the manner in which they handled Hansen after he received a heavy knock against Essendon in round 20, and also for the way they have responded to AFL investigators Brett Clothier and Abraham Haddad in recent weeks.

The AFL has been unimpressed with the club’s handling of the issue, although the Kangaroos have bristled at suggestions football manager Donald McDonald had influenced the testimony of key figures involved.

The letter is not the first step, rather the end step in a process that allows the medical board of the AFL to investigate how the practices of player protection is put in place. Is it oversight? You bet and I feel that the AFL does something much-needed in all professional sports. Really, it is only applicable to the pros because of the resources, however it could translate to large colleges as well.

In Zurich I spoke to Dr. McCrory about what they do in regards to this, here are the basics; Continue reading →

Dvorak – it has to be based on timing and complexity of each recovery – case-by-case basis

Putukian – if we can’t agree on dx how can we agree on a number

Overall theme is it is individualized, not all concussions are the same (Cantu)

Who is best qualified to make the sideline decision?

Cantu – multiple members working under a physician can make the call

Herring – concerning to him that some information is intrinsic to doctors so need to be careful

better question is who best qualified – person with most experience

Dvorak – looking at spectrum of games played, doctors are best qualified in most instances, but are they there in all matches? We should aim all this to the “grass roots” as the professional level there is more than adequate coverage.

comedy about football versus american football

Ellenbogen – those that know the athletes should be making the decision, maybe a parent in youth sports, or athletic trainers, understanding the patients baseline is important

Putukian – balancing act, in a perfect world its a team approach (Athletic Trainer mention), and she says in the US the athletic trainer should be making the decisions on the sidelines…

Aubrey – Hockey Canada has a safety person (volunteer) in lieu of an athletic trainer

Cantu – brings up possibly training school teachers in concussion

Herring – if you are team physician do you need someone else to make the decision if you are on the sideline? Panel – no

Is there a role for grading concussions?

Cantu – not perfect, but informing patient is important about severity and duration of recovery, after the fact

McCrory – we have moved from grading, look at the recovery – perhaps look at the SCAT/serial testing

Putukian – looking at history is more important than arbitrary “grade”

Herring – may help with continual care from one place to another, but again important to understand history

Should we be returning on the same day of concussion?

Aubrey – what about the NHL player in the playoffs (rhetorical question)

Cantu – no once recognized

McCrory – what about the players that clear the SCAT, so no concussion, but you know something is amiss?

Putukian – example of hockey player with delayed symptoms

McCrory – concussion is often an evolving injury

Ellenbogen – it is a traumatic brain injury, is the game worth it? No.

Panel – consensus is NO RTP same day

McCrory to Aubrey about playoff example – what about a regular season, and Aubrey is being very honest, and he feels the player push back is greater

Ken Dryden from the audience – why are we treating professional athletes different from the youth or non-elite athlete

We are starting to move away from that, all athletes should be treated the same

Should there be helmets in woman’s lacrosse and field hockey?

Cantu – yes, because of stick and ball causation of concussion

Putukian – no, change nature of the game, no reports of intercranial bleeds in women’s lacrosse, weary of unintended consequences (BTW, probably has the most experience with this)

Cantu and Putukian discussing this topic

Change gears – what about football?

Dvorak not in FIFA’s plans to recommend, many reasons including the false security of wearing head gear

Audience Q: should we discourage the use of the head bands/head gear

Dvorak – your own prerogative but data does not support the use of them as recommendation (Czech goalie wears one)

McIntosh – Rules are more important at this time

Should there be age restriction on tackling in American football, heading in soccer and checking in ice hockey?

Cantu – his words speak for themselves, youth sports needs to look at how the game is played because of the differences between older

McCrory – in Australia you cannot get to the gladiatorial aspect of Aussie Rules until they are “of age” (13 if I heard correctly)

Ellenbogen – risk of activity, most concussions via CDC information is from wheeled sports and recreation, does not make sense at this time to him, advise accordingly

Cantu – youth sports don’t have the good data, personally he does not believe learning a sport at age 5 will make you elite, it is a genetic disposition in his opinion

Putukian – it makes sense to decrease exposure, US Lacrosse has put age 13 on checking, her take on soccer is that there is no data to support this when using proper sized ball and equipment

Dvorak – young soccer players learn sport first, and fundamentals of “football” its not “headball”, studies done on heading ball and with study there was no increase in biomarkers they were looking at it. They don’t force kids to head ball until skills are sufficient.

Herring – false warranty? Arbitrary age is concerning, take head out of the game rather then taking the game away from youth athletes. The limit to exposure is accurate, but complete removal of the sport may not be necessary.

Cantu – sport needs to be safer for younger athletes

Aubrey – ice hockey has set limits on age for body checking, research is very important, it will help make decisions

With the NFL season getting started last Wednesday night, player health, at all levels, comes to the front of my mind. I have recently been thinking about health insurance with respect to sports. Living in Canada, it is definitely less of concern than in the U.S., but I thought I would share some thoughts about the college and pro levels of sport.

There is no way that I’m the first person, after all this time, to talk about what colleges and pro teams are doing about health insurance for players. I know there are a bunch of questions about whether or not concussions are pre-existing conditions, and other reasons players can’t be insured, but it should be a legitimate issue at the college and pro-level for contact sports. The NFL, NHL and NCAA have enough financial wherewithal to encourage some forward thinking insurance company to insure the players who are, perhaps unwittingly, putting their future well-being in jeopardy on the field of play.

As has been reported countless times, concussions are caused in a number of ways and the symptoms are diverse. So why should it be forced into the same insurance categories as other injuries with the “pre-existing” condition clause? If there was enough demand for some type of concussion insurance, a new category for a specific league/sport could be created. Taking care of players once Continue reading →

If you get the chance you should take the time to read the research that has been done by David Hovda, PhD and Kevin Guskiewicz, PhD, ATC; not only is it good information but it has been some of the leading information. These two gentleman do a great job of explaining the issues and making them more tangible for everyone.

ScienceLive, Science magazine’s weekly web discussions with experts in various fields, will examine the issue of sports- and combat-related head injuries during a web chat at 3 p.m. Eastern today. Guests include Kevin Guskiewicz of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center at The University of North Carolina at Chapel Hill and David Allen Hovda, the Director of the UCLA Brain Injury Research Center.

You can click the link above to go and read the replay of the chat, a must for those looking for information and would be a good idea if you have kids playing sports now. Below are selected comments from the chat; Continue reading →

Cleveland Browns’ team physician spoke at the rookie symposium to warn the incoming players not to hide symptoms of concussions;

At the rookie symposium, Shickendantz said the league cares about the players’ well-being.

“Our only agenda is your health and safety,” he said. “It’s about you, not about us.”

The reality is it’s about everyone. It’s true that players sometimes avoid getting checked out by team doctors because they don’t want to be removed from games, and it’s true that’s a very bad idea. But it’s also true that sometimes players are mistakenly cleared to return to games even when they have been checked out by team doctors, and that’s a bad mistake.

Check out Michael David Smith’s quick take on Shickendantz being the selected speaker. It will be very difficult to change the culture at the professional level (see money), it needs to begin at the youth level.

He may have took the time to address the concussion issue, however Steve Young really said nothing about concussions. Even downplaying his own concussions during his career. However he does feel the NFL is on the right path;

“I saw a quote from one of the players who suspected that in 20 years it wouldn’t be football any more,” Young said. “I think that scared everybody.”

However Young believes the NFL is taking proper steps to make sure today’s players won’t be as affected in the future by concussions.

“The league is getting serious about it and they know that it is important,” he said. “Now they have a whole way of dealing with it and there’s a protocol for how it’s handled. I talked to Aaron Rodgers and Tom Brady about this recently and both felt very strongly that they’re getting the best care. Once you have a concussion, it is very hard to get back on the field.”

Thanks to our heads up commenter Concerned Mom I perused two videos that she linked up. They are produced and posted onto YouTube by the Massachusetts School of Law. In the two-part series you will learn what we know and are learning; being in Massachusetts there is access to the BSTE (Nowinski, Cantu, Stern and McKee group).

Both videos are an hour in length but are again worth the time to sort out some things you may find questionable. As with most information regarding concussions it is hard to agree with ABSOLUTELY every part of this information, but it is as one person told me “worth posting”.

In the second one at 17:04 mark is where the now famous statement from Dr. Cantu on collisions sports and those under the age of 14. It echos what we have come to accept at this point. The way collision sports are being played currently are not a safe ground for youth and adolescent brains.

With all the illogical conclusions that are happening in the press there are some small positives already. The biggest of which, less than 24 hours after the untimely death of a great individual is the former players speaking out about depression and post-career condition. No longer has it become taboo to talk of depression.

Now players need to take stock of their physical and mental health, some players are such as Emmitt Smith;

“Depression & suicide are serious matters and we as current and former NFL players should demand better treatment. Lack of info … no more!!!,” former Dallas Cowboys Hall of Fame running back Emmitt Smith said on his Twitter account.

“And for you current players who think this issue doesn’t effect u. Get your head out of your but. Where u r 2day was his (Seau’s) yesterday.”

In the same article James Johnston Jr., had this comment on former NFL’ers; Continue reading →

First and foremost there is no “scientific” evidence of actual medical effectiveness with the product, however there has been recent and popular observational data to suggest that this modality and product may help. The said product is the GyroStim;

The GyroStim™ is a fully automated, computer-controlled multi-axis rotating chair. Its spacious design is comfortable and safe, and can accommodate many types of individuals ranging from small children to elite athletes to those with significant disabilities.

I bet any sports fan out there has seen it, it was highlighted in the recovery of Sidney Crosby and most recently another NHL star Guillaume Latendresse of the Minnesota Wild. The thought process is that when a concussion occurs one of the systems affected is the vestibular. For the layman the vestibular system is responsible for our awareness in space using very fine and specific equipment in the inner ear. Imagine when you were younger and had just gotten out of a pool from swimming and had water in your ears, then you decided to shake your head or run real fast and found yourself “a bit off”. This is similar in nature with a concussion, the violent forces to the head can create a disruption of this system, Continue reading →

There has been a lot of press about concussions the past weekend, mainly due to the NFL draft, however much information is out there (thanks to Concerned Mom for highlighting some in the comment section). Here is a quick rundown with links that I find interesting.

Supporting that contention will be the fact that no NFL player has retired due to fear of potential harm from concussions. Yes, some have retired due to the immediate consequences of multiple concussions. But no NFL player, current or prospective, has passed on playing football at its highest level due merely to the fear that the player may suffer one or more concussions that may cause problems for him later in life.[…]

That’s not to say that claims regarding the NFL’s failure to take meaningful steps before 2009 to protect players from concussions will lack merit. But as players who now know all they need to know about the risks associated with playing football continue to flock to the NFL, it will be harder and harder to get a judge or a jury to accept that players would have walked away from the sport if they had known then what all players know now.

Yesterday I helped launch the #C4CT cause via the blog and twitter and it was nice to see the interest really begin to peak (thanks @SchuttSports, @the_jockdoc and many others). As with most movements or introduction of products getting interest is the first thing; now with official press release in hand it is time to explain and get more of us going here.

The hard work of Jack Brewer and Alex Nennig (and probably others) of Brewer Sports International have created this coalition which I believe to be a “best foot forward” approach in not only raising awareness and education of concussions (our number on goal on The Concussion Blog) but has a possibility to stake a claim in treatment of lasting effects of TBI. I am honored to be asked to be a primary supporter of this cause, although as it catches wild-fire I am hopeful more important people jump aboard – looking at you NFLPA and NFL.

It is also an honor to be along side a very strong and promising law student in Paul Anderson. I have had many conversations about creating such a cause, but have yet to find the trailblazing counterparts until this came along. Please take the time to read the below press release and join along this weekend in using the #C4CT, even promoting questions from others about the hash tag is an opportunity to inform!

Below is our suggestions for the NHL regarding the Raffi Torres hit from last night – BTW it was described by me as pure thuggery – regardless after some time thinking we have composed our thoughts in the format used by the league;

Option A

I am Brendan Shanahan of the National Hockey Leagues’ Player Safety. Tuesday night in Chicago there was an incident that involved Raffi Torres of the Phoenix Coyotes and Marian Hossaof the Chicago Blackhawks. This particular incident was not penalized at the time but after reviewing the film and interviews we have determined further discipline is warranted.

In the 1st period Raffi Torres hit Hossa in the open ice, but as you can CLEARLY see the puck was not in the vicinity of either player nor was it just immediately played by Hossa. As Torres delivered the contact he left the ice and his principal point of contact was with his shoulder to the head of Hossa.

This is a clear violation of SO MANY rules; Rule 48 with states […] and Charging which states […] being the main concern. Also very disturbing is the blatant lack of respect of a fellow player on the ice.

You know how I feel about hockey, I love it; and playoff hockey is even more exciting. The best sporting event I have ever attended was Game 6 of the Detroit/Colorado Series in 1997, there is just something about playoff hockey. There is also one thing that is becoming more evident about playoff hockey; complete lack of consistency regarding player safety, in particular concussions.

On Friday Ryan Lambert wrote a very poignant article about the “concussion culture” and why it “sucks”. He basically took to task the NHL and their scaling back of awareness and proper management of the concussion;

We take concussions very seriously,” says the National Hockey League.

“Oh really? That’s great,” says the sports fan. “How?”

“Umm well you see…” replies the NHL, trailing off and looking at the tops of its feet. Continue reading →

So last night Shea Webber bounced Henrick Zetterberg’s head off the glass twice, the intent was obvious; Weber intended to repudiate the questionable check with some “on ice justice” with a hit to the head (you can see a .gif here). With head contact such a high priority of the NHL and its Player Safety department, headed by Brendan Shanahan, many thought there would be penalties coming down for Weber.

Tis the season for undisclosed and cryptic injuries; the regular season is now over as 14 teams have moved to the golf course for the summer. The NHL’s Second Season is upon us and the pressure has ratcheted up significantly, meaning finding and seeing proper management of any injury – let alone concussions – can be put to the test.

The machismo of sport and the pressure to win the Stanley Cup are so high that players, coaches, and even medical staff’s will take risks to achieve that goal. If there is one injury that needs to be handled the same, every time, no matter the context Continue reading →

A huge shout out to Pat Hickey of the Montreal Gazette for jumping on this story from the get-go and now he has exposed even more troubling issues with how this concussion was actually handled. Lets remind people: that even though they call it “mild” there is nothing mild about any concussion.

Hickey has discovered that the Price injury did not occur recently (as they suggested in his previous story above), the Canadians actually mentioned his injury occurred on March 20th, this creates major issues;

That leads to the second issue and this one is a bit troubling. The March 20 date for the Desharnais hit means that Price played four games after suffering concussion. It means that he took seven flights, which any doctor will tell you isn’t advised.

The delay between the initial contact and Price’s decision Sunday to tell the team’s medical staff that he was having headaches and they weren’t going away indicates that the National Hockey League’s program to identify and treat concussions isn’t going to work if the players don’t recognize the fact they are injured. Continue reading →

What is so absurd about calling a concussion a concussion… NOTHING. However one example of a team going to the absurd to avoid the actual word is the Montreal Canadians. Pat Hickey of the Montreal Gazette (via Yahoo! Sports) wrote about this ridiculousness occurring around Carey Price;

“He’s experiencing a lot of things that a lot of other guys are experiencing, and I think it’s still up in the air as to how to go about treating what we just term as headaches,” Cunneyworth said. “We’ve talked about this before, confusing the flu-like symptoms with the other things that go on. At this point, we’re just evaluating a guy that obviously we’re going to take our time with and make sure the process is taken care of.”

Yeah you are seeing that correct teams are now using the “flu-like symptom” tag on players experiencing dizziness, headaches and fatigue; interestingly Continue reading →

John-Michael Liles of the Toronto Maple Leafs has had to endure the recovery from concussion in the midst of a playoff push by the team. Having a concussion is nothing new to Liles – last year he sustained on for the Avalanche – but recovering mid-season is a whole new experience. A process that is littered with many pitfalls; the greatest of which is pushing too hard and delaying the already arduous return to play.

For a series of seemingly endless mornings after the concussion, Liles would awake and obsessively check for symptoms, hoping they would finally disappear and he could begin the recovery process. “Maybe you wake up and you feel good and then 20 minutes later you’re like ‘Man, I don’t feel good’,” he recalled. “It’s little things that can trigger it … You walk up a set of stairs sometimes and you’re like ‘Ah man, that was dumb’. It’s not like something where you do it and all of a sudden you’re like laying on the ground, but it’s something that you notice where on a normal day it would be something that you wouldn’t even think twice about.”

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